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Rosli MSA, Heidari E. Re-audit of the use of flumazenil following midazolam-induced conscious sedation. BDJ Open 2023; 9:36. [PMID: 37542050 PMCID: PMC10403577 DOI: 10.1038/s41405-023-00163-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 08/06/2023] Open
Abstract
INTRODUCTION Flumazenil is an antagonist drug of Benzodiazepam (BDZ) that has been used as a reversal agent of midazolam-induced conscious sedation (CS) in both emergency and elective procedures. For CS procedure, a high-quality record keeping and clinical justification prior to admission of flumazenil are recommended. Clinical Audit (CA) enables clinicians to evaluate the quality and standard of recorded clinical procedures. METHODS This re-audit investigated the reasons for the use of flumazenil and record keeping's quality with particular emphasis on CS. In this retrospective reaudit, the authors looked at the patients' records who had received dental care under CS in the Sedation and Special Care Department of (SSCD), United Kingdom from January to June 2022. RESULTS Out of 665 patients who received midazolam-induced CS, 21 patients were administered IV Flumazenil. The commonest reason (9, 42.8%) was due to prolonged recovery. CONCLUSION This re-audit highlighted the need for administrating flumazenil in certain patient groups, and/or circumstances (not emergency). The importance of maintaining high-quality record keeping is discussed.
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Affiliation(s)
- Muhammad Syafiq Asyraf Rosli
- Clinical Lecturer, Faculty of Dentistry, National University of Malaysia, Kuala Lumpur, Malaysia.
- Postgraduate Dentist, Sedation and Special Care Department, Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, London, UK.
| | - Ellie Heidari
- Senior Specialist Clinical Teacher, Centre for Dental Education, Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, London, UK
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Walke SS, Chauhan S, Pandey V, Jadhav R, Chaudhari V, Vishwanathan D, Kolhe K, Ingle M. When to Discharge a Patient After Endoscopy: A Narrative Review. Clin Endosc 2022; 55:8-14. [PMID: 35135177 PMCID: PMC8831418 DOI: 10.5946/ce.2021.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 06/08/2021] [Indexed: 11/14/2022] Open
Abstract
Video endoscopy is an important modality for the diagnosis and treatment of various gastrointestinal diseases. Most endoscopic procedures are performed as outpatient basis, sometimes requiring sedation and deeper levels of anesthesia. Moreover, advances in endoscopic techniques have allowed invasion into the third space and the performance of technically difficult procedures that require the utmost precision. Hence, formulating strategies for the discharge of patients requiring endoscopy is clinically and legally challenging. In this review, we have discussed the various criteria and scores for the discharge of patients who have undergone endoscopic procedures with and without anesthesia.
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Affiliation(s)
| | | | - Vikas Pandey
- Department of Gastroenterology, LTMMC & LTMGH, Sion, Mumbai, India
| | - Rahul Jadhav
- Department of Gastroenterology, LTMMC & LTMGH, Sion, Mumbai, India
| | - Vipul Chaudhari
- Department of Gastroenterology, LTMMC & LTMGH, Sion, Mumbai, India
| | | | - Kailash Kolhe
- Department of Gastroenterology, LTMMC & LTMGH, Sion, Mumbai, India
| | - Meghraj Ingle
- Department of Gastroenterology, LTMMC & LTMGH, Sion, Mumbai, India
- Correspondence: Meghraj Ingle Department of gastroenterology, LTMMC & LTMGH, Endoscopy room 13, College building, First Floor, Sion, Mumbai 400022, India Tel: +91-93209-79659, Fax: +91-022-240-63000, E-mail:
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Jin HJ, Shin MH, Myung E. Factors Affecting Recovery Time after Sedation for Upper Gastrointestinal Endoscopy. Chonnam Med J 2020; 56:191-195. [PMID: 33014758 PMCID: PMC7520373 DOI: 10.4068/cmj.2020.56.3.191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/18/2020] [Accepted: 08/19/2020] [Indexed: 12/04/2022] Open
Abstract
The purpose of this study was to investigate factors affecting recovery time after sedation for upper gastrointestinal endoscopy. The study population included 1310 patients in the national gastric cancer screening program who received sedation for upper gastrointestinal endoscopy from April 15, 2015 to December 31, 2018. Multivariate regression analysis was performed to identify factors related to recovery time. The mean recovery time after examination was 51.2 minutes (SD=13.3). Patients with a history of hypertension had a recovery time 2.59 minutes shorter than that of patients without hypertension (p=0.006, Bonferroni-corrected p=0.108). Patients with a history of stroke had a recovery time 9.41 minutes longer than that of patients without stroke (p=0.007, Bonferroni-corrected p=0.124). Patients who received 3 mg midazolam had a recovery time 2.99 minutes longer than that of patients received 2 mg (p=0.001, Bonferroni-corrected p=0.010), and patients who received less than 6 cc of propofol had a recovery time 2.90 minutes longer than those that of patients received 7-12 cc of propofol (p<0.001, Bonferroni-corrected p=0.005). These results suggest that receiving high doses of midazolam and having a history of stroke are associated with longer recovery times. Patients meeting these criteria should be managed carefully after sedation for upper gastrointestinal endoscopy.
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Affiliation(s)
- Hwa-jung Jin
- Department of Public Health, Graduate School, Chonnam National University Medical School, Gwangju, Korea
| | - Min-Ho Shin
- Department of Preventive Medicine, Chonnnam National University Medical School, Gwangju, Korea
| | - Eun Myung
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
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López-Picazo J, Alberca de Las Parras F, Sánchez Del Río A, Pérez Romero S, León Molina J, Júdez FJ. Quality indicators in digestive endoscopy: introduction to structure, process, and outcome common indicators. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 109:435-450. [PMID: 28553719 DOI: 10.17235/reed.2017.5035/2017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The general goal of the project wherein this paper is framed is the proposal of useful quality and safety procedures and indicators to facilitate quality improvement in digestive endoscopy units. This initial offspring sets forth procedures and indicators common to all digestive endoscopy procedures. First, a diagram of pre- and post-digestive endoscopy steps was developed. A group of health care quality and/or endoscopy experts under the auspices of the Sociedad Española de Patología Digestiva (Spanish Society of Digestive Diseases) carried out a qualitative review of the literature regarding the search for quality indicators in endoscopic procedures. Then, a paired analysis was used for the selection of literature references and their subsequent review. Twenty indicators were identified, including seven for structure, eleven for process (five pre-procedure, three intra-procedure, three post-procedure), and two for outcome. Quality of evidence was analyzed for each indicator using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification.
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Affiliation(s)
- Julio López-Picazo
- Servicio de Calidad Asistencial, Hospital Clínico Universitario Virgen de la Arrixaca
| | | | | | - Shirley Pérez Romero
- Servicio de Calidad Asistencial, Hospital Clínico Universitario Virgen de la Arrixaca
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Canadian Association of Gastroenterology Indicators of Safety Compromise following Colonoscopy in Clinical Practice. Can J Gastroenterol Hepatol 2016; 2016:2729871. [PMID: 27446832 PMCID: PMC4932159 DOI: 10.1155/2016/2729871] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 06/09/2016] [Indexed: 01/31/2023] Open
Abstract
In 2012 the Canadian Association of Gastroenterology published 19 indicators of safety compromise. We studied the incidence of these indicators by reviewing all colonoscopies performed in St. John's, NL, between January 1, 2012, and June 30, 2012. Results. A total of 3235 colonoscopies were included. Adverse events are as follows. Medication-related includes use of reversal agents 0.1%, hypoxia 9.9%, hypotension 15.4%, and hypertension 0.9%. No patients required CPR or experienced allergic reactions or laryngospasm/bronchospasm. The indicator, "sedation dosages in patients older than 70," showed lower usage of fentanyl and midazolam in elderly patients. Procedure-related immediate includes perforation 0.2%, immediate postpolypectomy bleeding 0.3%, need for hospital admission or transfer to the emergency department 0.1%, and severe persistent abdominal pain proven not to be perforation 0.4%. Instrument impaction was not seen. Procedure-related delayed includes death within 14 days 0.1%, unplanned health care visit within 14 days of the colonoscopy 1.8%, unplanned hospitalization within 14 days of the colonoscopy 0.6%, bleeding within 14 days of colonoscopy 0.2%, infection 0.03%, and metabolic complication 0.03%. Conclusions. The most common adverse events were mild and sedation related. Rates of serious adverse events were in keeping with published reports.
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Sims PG, Kates CH, Moyer DJ, Rollert MK, Todd DW. Anesthesia in outpatient facilities. J Oral Maxillofac Surg 2013; 70:e31-49. [PMID: 23128005 DOI: 10.1016/j.joms.2012.07.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Indicators of safety compromise in gastrointestinal endoscopy. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2012; 26:71-8. [PMID: 22312605 DOI: 10.1155/2012/782790] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION The importance of quality indicators has become increasingly recognized in gastrointestinal endoscopy. Patient safety requires the identification and monitoring of occurrences associated with harm or the potential for harm. The identification of relevant indicators of safety compromise is, therefore, a critical element that is key to the effective implementation of endoscopy quality improvement programs. OBJECTIVE To identify key indicators of safety compromise in gastrointestinal endoscopy. METHODS The Canadian Association of Gastroenterology Safety and Quality Indicators in Endoscopy Consensus Group was formed to address issues of quality in endoscopy. A subcommittee was formed to identify key safety indicators. A systematic literature review was undertaken, and articles pertinent to safety in endoscopy were identified and reviewed. All complications and measures used to document safety were recorded. From this, a preliminary list of 16 indicators was compiled and presented to the 35-person consensus group during a three-day meeting. A revised list of 20 items was subsequently put to the consensus group for vote for inclusion on the final list of safety indicators. Items were retained only if the consensus group highly agreed on their importance. RESULTS A total of 19 indicators of safety compromise were retained and grouped into the three following categories: medication-related - the need for CPR, use of reversal agents, hypoxia, hypotension, hypertension, sedation doses in patients older than 70 years of age, allergic reactions and laryngospasm⁄bronchospasm; procedure-related early - perforation, immediate postpolypectomy bleeding, need for hospital admission or transfer to emergency department from the gastroenterology unit, instrument impaction, severe persistent abdominal pain requiring evaluation proven to not be perforation; and procedure-related delayed - death within 30 days of procedure, 14-day unplanned hospitalization, 14-day unplanned contact with a health provider, gastrointestinal bleeding within 14 days of procedure, infection or symptomatic metabolic complications. CONCLUSIONS The 19 indicators of safety compromise in endoscopy, identified by a rigorous, evidence-based consensus process, provide clear outcomes to be recorded by all facilities as part of their continuing quality improvement programs.
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Armstrong D, Barkun A, Bridges R, Carter R, de Gara C, Dube C, Enns R, Hollingworth R, Macintosh D, Borgaonkar M, Forget S, Leontiadis G, Meddings J, Cotton P, Kuipers EJ. Canadian Association of Gastroenterology consensus guidelines on safety and quality indicators in endoscopy. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2012; 26:17-31. [PMID: 22308578 PMCID: PMC3275402 DOI: 10.1155/2012/173739] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2011] [Accepted: 10/04/2011] [Indexed: 12/21/2022]
Abstract
BACKGROUND Increasing use of gastrointestinal endoscopy, particularly for colorectal cancer screening, and increasing emphasis on health care quality, highlight the need for clearly defined, evidence-based processes to support quality improvement in endoscopy. OBJECTIVE To identify processes and indicators of quality and safety relevant to high-quality endoscopy service delivery. METHODS A multidisciplinary group of 35 voting participants developed recommendation statements and performance indicators. Systematic literature searches generated 50 initial statements that were revised iteratively following a modified Delphi approach using a web-based evaluation and voting tool. Statement development and evidence evaluation followed the AGREE (Appraisal of Guidelines, REsearch and Evaluation) and GRADE (Grading of Recommendations, Assessment, Development and Evaluation) guidelines. At the consensus conference, participants voted anonymously on all statements using a 6-point scale. Subsequent web-based voting evaluated recommendations for specific, individual quality indicators, safety indicators and mandatory endoscopy reporting fields. Consensus was defined a priori as agreement by 80% of participants. RESULTS Consensus was reached on 23 recommendation statements addressing the following: ethics (statement 1: agreement 100%), facility standards and policies (statements 2 to 9: 90% to 100%), quality assurance (statements 10 to 13: 94% to 100%), training, education, competency and privileges (statements 14 to 19: 97% to 100%), endoscopy reporting standards (statements 20 and 21: 97% to 100%) and patient perceptions (statements 22 and 23: 100%). Additionally, 18 quality indicators (agreement 83% to 100%), 20 safety indicators (agreement 77% to 100%) and 23 recommended endoscopy-reporting elements (agreement 91% to 100%) were identified. DISCUSSION The consensus process identified a clear need for high-quality clinical and outcomes research to support quality improvement in the delivery of endoscopy services. CONCLUSIONS The guidelines support quality improvement in endoscopy by providing explicit recommendations on systematic monitoring, assessment and modification of endoscopy service delivery to yield benefits for all patients affected by the practice of gastrointestinal endoscopy.
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Affiliation(s)
- David Armstrong
- Division of Gastroenterrology, McMaster University, Hamilton, Ontario, Canada.
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Lightdale JR, Valim C, Newburg AR, Mahoney LB, Zgleszewski S, Fox VL. Efficiency of propofol versus midazolam and fentanyl sedation at a pediatric teaching hospital: a prospective study. Gastrointest Endosc 2008; 67:1067-75. [PMID: 18367187 DOI: 10.1016/j.gie.2007.11.038] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2007] [Accepted: 11/12/2007] [Indexed: 12/28/2022]
Abstract
BACKGROUND Many pediatric endoscopists are adopting propofol in their practices, with the expectation that propofol will increase their overall efficiency. OBJECTIVE AND SETTING To compare the efficiency of propofol versus midazolam and fentanyl by measuring elapsed times between initial intravenous administration and patient discharge at a pediatric teaching hospital. DESIGN Endoscopy times were prospectively collected for consecutive patients who were undergoing either anesthesiologist-administered propofol or endoscopist-administered midazolam and fentanyl. The effect of the type of sedation on these times was assessed by using multiple linear regression by adjusting for other candidate predictors, including concomitant use of other sedatives, endotracheal intubation by anesthesiologists, and the presence of fellow trainees. MAIN OUTCOME MEASUREMENTS Time to onset of sedation (time sedation started to scope in), procedure time (endoscope in to endoscope out), discharge time (endoscope out to hospital discharge), and total time (sedation started to hospital discharge). RESULTS The times for 134 children (mean age 12 +/- 5 years) to receive propofol sedation were compared with those of 195 children (13 +/- 5 years) who received midazolam and fentanyl. Midazolam and fentanyl cases disproportionately included EGDs (P < .001) and patients who were classified as American Society of Anesthesiologists I (P < .03). Patients who received propofol had shorter times until sedated, similar procedure times, longer discharge times, and comparable total times. Multivariate analyses confirmed that fellow participation prolonged the procedure times (P < .0001), and endotracheal intubation prolonged propofol times (P <. 01), but adjusting for these did not change the comparison results. CONCLUSIONS Anesthesiologist-administered propofol sedation in a pediatric teaching endoscopy unit may not lead to faster hospital times when compared with endoscopist-administered midazolam and fentanyl. These results are not explained by controlling for patient characteristics, the presence of a trainee, the sedative doses, or endotracheal intubation for airway management.
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Affiliation(s)
- Jenifer R Lightdale
- Division of Gastroenterology, Children's Hospital Boston, Boston, Massachusetts 02115, USA
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Anesthesia and sedation outside the operating room: how to prevent risk and maintain good quality. Curr Opin Anaesthesiol 2007; 20:513-9. [DOI: 10.1097/aco.0b013e3282f06ba6] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Heuss LT, Schnieper P, Drewe J, Pflimlin E, Beglinger C. Safety of propofol for conscious sedation during endoscopic procedures in high-risk patients-a prospective, controlled study. Am J Gastroenterol 2003; 98:1751-7. [PMID: 12907329 DOI: 10.1111/j.1572-0241.2003.07596.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Propofol, a rapidly-acting hypnotic agent, is increasingly being used for endoscopic sedation. Serious adverse effects, including respiratory and cardiovascular depression, make many endoscopists reluctant to use propofol in critically ill patients. This study characterizes propofol's safety profile in consecutive high-risk patients (American Society of Anesthesiologists [ASA] classes III and IV) compared with matched subjects (ASA classes I and II). METHODS During a 19-month period, 1370 at risk-patients were sedated with propofol, of whom 47% (614 ASA III, 28 ASA IV) were age matched with 642 consecutive patients of the same gender and age assigned to ASA classes I and II and undergoing the same endoscopic procedures (395 gastroscopies, 201 colonoscopies, 14 combined). Registered nurses performed all sedations by propofol dose titration while carefully monitoring arterial oxygen saturation, heart rate, and blood pressure. RESULTS No major complications occurred among the critically ill patients. There was, however, an increased risk for a short relevant oxygen desaturation (<90%) of 3.6% for ASA III and IV versus 1.7% for ASA I and II (p = 0.036). In four versus one case, short mask ventilation was necessary. Also, a greater proportion of patients showed a > or =5% oxygen saturation decrease. There was no pronounced influence on arterial pressure or heart rate and no perforations in 336 colonoscopies. CONCLUSIONS With careful monitoring, propofol sedation during GI endoscopies is safe, even for high-risk patients. Considering their higher comorbidity and tendency toward oxygen desaturation, they need particularly careful monitoring, and the required dose is, on mean, 10-20% lower than in ASA classes I and II.
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Affiliation(s)
- Ludwig T Heuss
- Department of Gastroenterology, University Hospital Basel, Basel, Switzerland
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Rowe WS, Yaffe MJ, Pepler C, Dulka IM. Variables impacting on patients' perceptions of discharge from short-stay hospitalisation or same-day surgery. HEALTH & SOCIAL CARE IN THE COMMUNITY 2000; 8:362-371. [PMID: 11560706 DOI: 10.1046/j.1365-2524.2000.00261.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
The paper presents components of a study (n = 929) that was designed to examine, at one specific point in time, the hospital experience of the patient and the patient's corresponding recovery at home. Variables that captured the hospitalization and recovery experience relate to the degree of patient involvement in decisions about their treatment and discharge plans. Levels of health and recovery-related information reported by patients and their level of confidence in ability to resume regular activities once home were also measured. In general, individuals reported what many would consider having received less than optimal levels of information about their illness and recovery at home. Many patients also reported that they neither participated, nor were consulted on their needs or perceptions during their hospitalization. Expectations were that problems that patients might experience once home would have their origins in problems from within the community. However, the community resources were found to be less implicated and hospital resources more so. This suggests the importance of examining institutional issues even when one is focusing on the delivery of community services.
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Affiliation(s)
- William S. Rowe
- School of Social Work and The Centre for Applied Family Studies,Family Medical Centre, St. Mary's Hospital andSchool of Nursing, McGill University, Montreal, Quebec, Canada
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